Care Home: 49 Victor Street

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What the care home does well People like living at the service and feel that the service meets their needs. Comments include: `We have meetings to talk about things`, ` I like it here` and `The staff are good they listen to use`. Prior to people moving to the service an assessment of their needs is completed to make sure the service can meet their needs. People have the opportunity to visit the service to make sure they want to live there. People views are regularly sought and the service acts upon issues they raise. People choose how they live their life and people are treated as individuals with their own individual needs. People`s different lifestyles are supported. Support is designed to promote people`s choices and to promote their independence. People choose how to spend their time and choose the activities they want to do. For example one person has part time employment and also does voluntary work. Another person goes to a day centre and follows his interest in art. The service promotes ordinary living principles and staff view the service as the home of the people that live there. One staffmember said `I am the visitor and it is their home`. The people living there take responsibility for who enters the service and always answer the telephone. The service supports people to manage their own health care and to look after their own medication. Staff are well trained to provide people with the support they need. Staffing is flexible to provide one to one support when needed. Staffing can be increased when people`s needs change. The service is well led and has had consistent management for many years. The service has systems in place to review and monitor the service and has plans in place to further develop the service. What has improved since the last inspection? Since we visited last time the service has addressed all the requirements and recommendations we made. The service is now making sure that the recruitment procedures ensure that copies of references are kept on file. This has increased the protection for people living at the service. A formalised system has been put in place to review and monitor the service. This takes account of people`s views and demonstrates how the service responds to issues raised by the people living there. Individual risk assessments are reviewed meaning that staff have all the up to date information to provide people with appropriate support. Safeguarding training has been provided to all staff. This will make sure staff have the knowledge to protect people and to respond if incidents should occur. What the care home could do better: We made no requirements or recommendations following this inspection. CARE HOME ADULTS 18-65 49 Victor Street, Stone Staffordshire ST15 8HL Lead Inspector Jane Capron Unannounced Inspection 6th January 2009 11:00 DS0000005110.V373682.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000005110.V373682.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000005110.V373682.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 49 Victor Street, Address Stone Staffordshire ST15 8HL Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01785 615500 RMP Care Miss Lorraine Paula Lawton Care Home 5 Category(ies) of Learning disability (5) registration, with number of places DS0000005110.V373682.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care Home Only - Code PC; to service users of the following gender; either. Whose primary care needs on admission to the home are within the following categories: - Learning Disabilities - Code LD The maximum number of service users who can be accommodated is 5. 2. Date of last inspection 31st August 2006 Brief Description of the Service: 49 Victor Street provides services for five people in two terraced houses with an adjoining door. The people living in each house live and are are supported separately The front doors open directly on to the pavement, and to the rear of the properties there are yards leading to a lawn area. Beyond the secure boundary of the property, is the London to Manchester railway line. The home provides accommodation in five single rooms, for people who have a Learning Disability. It is the stated intention of the providers, that this shall be in the nearest style to a family domestic setting, as can be achieved for the people living there. Each property has communal areas downstairs. One property has the bathroom downstairs with a toilet upstairs. The other property has an upstairs bathroom with separate shower. One of the properties has a sleep in room but all rooms have the provision of an alarm system. The home operates a no smoking policy. The service seeks to maximise the independence of each person living there. The fees are not included in the service user guide as the fee level is determined on each person’s needs. People considering moving to the service would need to contact the service to discuss the cost of a placement. DS0000005110.V373682.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service 3 star. This means the people who use this service experience excellent quality outcomes. This inspection lasted approximately five and a half hours. The service was told the day before that we would be visiting. This was to ensure that people that lived there and staff would be available. The inspection included information provided in the service’s Annual Quality Assurance Assessment. This is a document that the service writes to tell the commission about the service they offer and improvements they have made and plans for the future. We also received a survey from three of the people living there. During the inspection we talked to two people that live there, several staff and the manager of the service. We also looked at a sample of documents relating to the care provided. We looked at information about how the service consults with people and how it responds to issues raised by the people that live there. We also looked at a sample of staff files and information about how the service reviews and monitors the service it provides. We looked at a sample of the accommodation. What the service does well: People like living at the service and feel that the service meets their needs. Comments include: ‘We have meetings to talk about things’, ‘ I like it here’ and ‘The staff are good they listen to use’. Prior to people moving to the service an assessment of their needs is completed to make sure the service can meet their needs. People have the opportunity to visit the service to make sure they want to live there. People views are regularly sought and the service acts upon issues they raise. People choose how they live their life and people are treated as individuals with their own individual needs. People’s different lifestyles are supported. Support is designed to promote people’s choices and to promote their independence. People choose how to spend their time and choose the activities they want to do. For example one person has part time employment and also does voluntary work. Another person goes to a day centre and follows his interest in art. The service promotes ordinary living principles and staff view the service as the home of the people that live there. One staffmember said ‘I am the visitor and it is their home’. The people living DS0000005110.V373682.R01.S.doc Version 5.2 Page 6 there take responsibility for who enters the service and always answer the telephone. The service supports people to manage their own health care and to look after their own medication. Staff are well trained to provide people with the support they need. Staffing is flexible to provide one to one support when needed. Staffing can be increased when people’s needs change. The service is well led and has had consistent management for many years. The service has systems in place to review and monitor the service and has plans in place to further develop the service. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can DS0000005110.V373682.R01.S.doc Version 5.2 Page 7 be made available in other formats on request. DS0000005110.V373682.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000005110.V373682.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People considering moving to the service can be confident that they will be provided with information about the service and that an assessment of their needs will be completed to make sure that the service can meet their needs. EVIDENCE: The service’s Annual Quality Assurance Assessment (AQAA) states that they provide detailed information in a Statement of Purpose and Service User Guide and that anyone considering moving to the service has their needs assessed by the local authority and the service. Copies of the Service User Guide are in people’s files. These documents have been updated to include clearer information about charges such as holidays and transport. Documents include pictures to assist people to understand them better. When we spoke to one person they told us they had information about the service before they came to live there. This was confirmed by the information in the surveys we received. DS0000005110.V373682.R01.S.doc Version 5.2 Page 10 There have been no recent admissions but we saw evidence that assessments are completed for people considering using the service. One person is currently considering the service and an assessment had been completed by the local authority and by the manager of the service. This covers the areas of mental and physical health, independent living skills, social care needs, communication, spiritual and any cultural needs and dietary needs. We spoke to the manager and she could describe the admission process that included an assessment and visits to the service by people considering living there. One person living there also said he visited service before deciding to move in. DS0000005110.V373682.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. People can be assured that they will be fully involved in decisions about their lives and that the support they receive will be based on their individual needs and preferences. EVIDENCE: The service’s AQAA states that ‘care planning is undertaken with the full involvement of the people that live at the home, planning their own meetings and inviting who they want to attend’. The files of two people were looked at as part of this inspection and these identify people’s needs relating to their health and personal care, mobility, communication, dietary needs and social care and include their likes and dislikes. These are presented in a person centred way and people living at the service tell us they are fully involved in planning their own care. The service is providing information in a way that takes account of people’s specific communication needs. For example DS0000005110.V373682.R01.S.doc Version 5.2 Page 12 information about keeping safe both and out of the service is in an easily understandable way and includes information pictorially. Support plans and personal files are seen as belonging to the individual and one person said they keep their files in their bedroom and said ‘I put in when I go to the dentist’ and ‘I sign my file’. Reviews of people’s care take place and plans updated when changes occurred. For example one person recently had a fall and the plan had been altered to identify the additional support they needed. Also one person needed additional night support and the service has put a night sleep in staff member to make sure the person is safe. Plans include individual targets chosen by the person concerned. For example one person wants to learn how to use their digital camera better and this was identified in their review. When we spoke to staff they could describe people’s individual needs and the support they need. For example they could describe how they needed to communicate with one person who had specialist communication needs. Risk management systems that promote people’s independence are in place. Risks for each person are identified and show the support needed for people to undertake activities with acceptable risks. For example one person is managing his own money but has staff support to check his bank statements to ensure there are no discrepancies that could indicate abuse. Another person is nervous using steps so staff provide supervision to use the stairs to increased their confidence and the service has installed a handrail to the back steps. The AQAA states that the service acts upon individual’s needs and choices and actively seeks the views of people that live there to promote their choices. When we spoke to people they told us that they live the life they want and decide how to spend their time and choose what they want to do. The surveys we received confirm that choice is provided. Each person is treated as an individual making choices about their daily life. For example one person said he chooses to attend the day services and to go to work. He also said that he chooses how to spend his leisure time for example going out shopping, going to the pub and where to go on holiday. Another person said he enjoys playing darts and he went with staff to the local pub. These people also said they had been involved in choosing the colours of their bedrooms. Staff could describe how they promote people’s choices. For example one person needs help to make choices and can only choose from a small number of options. If they are offered too many options they find it difficult to cannot make a decision. The service continually seeks the views of the people that live there through house meetings, one to one talks and in everyday discussions. As a result of these consultations changes have been made for example installing an upstairs toilet at the request one person and being in the process of changing the kitchen cupboard handles. DS0000005110.V373682.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. People can be confident that they can live the lifestyle they choose taking part in activities of their choice and being supported to develop their skills and to have control over their lives. EVIDENCE: The AQAA states that it promotes a wide range of lifestyles and provides flexible staffing to enable people to access community facilities. We saw that the service supports people to live the lifestyle they want taking into account their diverse needs. One person said that they work at a local pub and a local supermarket two days a week and did voluntary work at the day centre a further two days a week. He has achieved a food safety qualification. He said how much he enjoys these jobs. This person also says that he goes swimming, goes out for meals and to cafés and goes to the pub with another person living there. He also said he goes on holiday every year and we saw DS0000005110.V373682.R01.S.doc Version 5.2 Page 14 photographs of places he has visited. Another person goes to a day centre for older people and also attends an art group. Examples of his paintings are evident in the living room. A third person said he goes to the day services and also goes shopping, to the pub and out for meals. He also said he had been to see a pop group and was hoping to visit London to see a musical show. People also said that they do tasks around the service including cleaning, cooking and laundry. The people living at the service are fully integrated into the local community. A relative of one person said her relative knows everyone in the area and is well liked and respected in the community. The service supports people to take an active part in the life of Stone, attending a range of local events including the Stone food festival, the farmer’s market and musical events. The service supports people to maintain relationships with family and friends. Two people regularly see their families and one relative visited during this inspection. She was very happy with the support her relative receives stating ‘I find it marvellous’ and ‘he has lots of opportunities’. The people living at the service have friends living in similar services near by and have regular contact, visiting each other and spending time out in the community together and choosing to go on holiday together. The service’s AQAA told us that one person had organised a party to which he had invited 40 family and friends. People said that the service has few rules and routines are flexibly based around people’s wishes. For example people get up and go to bed when they choose taking account of the activities they have decided to take part in. Bedrooms are lockable. There are no set times for meals and the routines respond to the decisions and choices of the people that live there. The service is their home and they take responsibility by, for example, answering the front door and answering the telephone. The AQAA said that the service promoted healthy lifestyles and uses fresh vegetables and fresh fruit. People said that they eat a lot of fruit and one person said he is going to go out to buy more bananas. People living at the service told us that they are involved in all parts of the meal process from food shopping, choosing the meals and cooking. One person said that there is a cooking rota and on their day they decide what to cook from provisions in the service making sure they consider what other people like. He said that the meals were good. The people living in the service choose to eat together although there are times when one or other of the people are not in for meals. The manager told us that if someone wants to eat separately they could choose to do so. The support plans show us that the service looks at the dietary needs of each person and if necessary puts in place a support plan to address such needs including regular weighing if needed. DS0000005110.V373682.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People can be assured that they will be supported to have their health care and medication needs met. EVIDENCE: The service’s AQAA states that people are registered with a doctor and are supported to receive both primary and specialist health cares services. They state that they liaise with health care staff to promote people’s health. Examination of support plans confirms that people are registered with the GP of their choice. Records show that people receive regular eye and dental checks and have regular chiropody care. One person said that he went to the doctor when he was ill and wrote in his plan when he had health appointments. His record shows regular dental and eye checks and that he sees the chiropodist every two months. He also said that he had fallen and the staff went to the hospital with him. A relative we spoke to said that her relative goes to the GP when he is ill and he goes to the dentist and optician. One person has physical and mental health needs and records are kept of health appointments and descriptions of his symptoms are kept so that staff DS0000005110.V373682.R01.S.doc Version 5.2 Page 16 can identify when specialist support is needed. A staff member we spoke to could describe these symptoms and knew how to respond. The AQAA states that the service promotes people to self medicate. Examination of a support plan shows that medication assessments are completed. One person that self-medicates said they keep their medication locked up and could tell us when they take their medication. The service also has procedures in place to check that people are taking their medication as prescribed. We observed that medication is kept securely in people’s bedroom in a locked box within a locked bedroom. People are keeping their own records of the medication they take. In respect of ‘as required’ medication, protocols are in place and staff support people with this medication. Records of these show that the staff and the person themselves are signing the records. Staff records confirm that staff are trained in administrating medication. DS0000005110.V373682.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People that live at the service can be assured that they can express concerns and that these will be listened to and acted upon. People can be confident that the staff know about safeguarding issues and will act to protect them from abuse. EVIDENCE: The service’s AQAA states that they ‘listen to views of people and act upon these immediately’. The service has a complaints procedure in place. We, the commission have received no complaints since the last inspection and we were advised the service had not received any either. People that live at the service said they know how to complain and this view was supported by the surveys we received from people living there. One person also said he used an advocacy service and was trained in self-advocacy. The service has a ‘grumbles’ and suggestion book where issues raised by people living there are recorded. Entries include one person’s wish for a different kind of cleaning equipment and a request for an updated telephone list. Both of these suggestions had been acted upon. An upstairs toilet had been installed following a request from one of the people living there. Records also show that regular house meetings take place where the views of people are sought. The survey we received also stated that the person felt that the staff listened to them and acted on what they said. The AQAA states that the company ‘does everything in its power to protect people from all forms of abuse’. A protection procedure is in place and DS0000005110.V373682.R01.S.doc Version 5.2 Page 18 training records confirm that staff are trained in safeguarding issues. A discussion with one staff member confirms she was aware of symptoms of abuse and knew how to respond appropriately. There have been no safeguarding incidents since our last inspection. We examined three personnel records and these confirmed that the service’s recruitment practices were protecting people by making sure that all pre employment checks were completed. The AQAA states that the service supported people to be as independent as possible in managing their money. Financial support plans are in place that show the type of support needed. The service is looking after one person’s money and records are kept of all expenditure and receipts kept. A check of this person’s money shows there to be a slight excess of cash and the service agreed to investigate this. In respect of the people managing their own money the service supports them to check their bank statements to make sure that that these are accurate and there are no concerns that money may have gone missing. DS0000005110.V373682.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,27,28,30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People can be confident that the accommodation is suitable to meet their needs and that the service will make any alterations it can to meet the changing needs of the people that live there. EVIDENCE: The service’s AQAA states that it provides a ‘small homely environment’ with bedrooms that are decorated to people’s choice and with suitable communal areas. The service is located in two adjoining houses in a row of terraced housing. The accommodation is provided in two terraced houses joined by an internal door. One house provides accommodation for three people who have lived there for a number of years. The next door property provides for two people and is currently unoccupied having been registered in November 2008. Although joined by one door the people living in the houses will be supported separately and any joint activities will be by mutual agreement. The accommodation is of the good standard. All bedrooms are single with one DS0000005110.V373682.R01.S.doc Version 5.2 Page 20 bedroom having an ensuite toilet. All are lockable and provide suitable private accommodation. The bedrooms seen are well personalised and several of the occupants have chosen to buy their own furniture. Each house provides suitable communal accommodation and the lounge provides a range of seating that meets the needs of the people that live there. Staircases have rails to support people to use the stairs safely. The accommodation in the newly registered part is of an exceptional standard, minor areas of the established service would benefit from some redecorating but the service informed us that it had plans to do so. The accommodation was seen to be clean and tidy. The surveys we received said the service is always clean and fresh. The people that live at the service are supported by staff to keep the service clean. One person said that he had vacuumed that morning and another person told us that he mopped the kitchen floor. Staff records confirm that most have completed training in infection control. DS0000005110.V373682.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. People can be confident that the service will provide trained and qualified staff in sufficient numbers to provide them with the support they need. People are protected by the way the service recruits its staff. EVIDENCE: The service’s AQAA states that it trains its staff and that the way it recruits its staff protects the people that live there. The service tells us that their staff turnover is low and therefore gives people consistent staff who have a ‘good understanding’ of the people that live there. Surveys we received said that the staff treat them well. A discussion with a relative said that they staff provide their relative with the support they need. Our discussions with staff show that they know the needs of each person living at the service and know how these individual needs can be met. Staff see the service as the people’s home and provide them with control over their own lives. One staff member said ‘I am the visitor’, ‘it is their home’. This staff DS0000005110.V373682.R01.S.doc Version 5.2 Page 22 member outlined how the service promotes people’s independence and supports people to have their needs met. The service tells us that due to having a number of services in a small area they can provide services with flexible staffing. The service has a basis of six staff but can call upon additionally staffing if needed. This allows increased staffing to be available to provide people with individual support and to increase staffing when needed. For example following one person having a fall the service has increased the staffing to provide them with additional support. Also due to another person needing night support the service has been able to provide a ‘sleep in’ staff member when previously this was not required. Staff are provided with a range of training. Talking with staff and examining training records confirms that they receive training in health and safety issues as well as health conditions and practice issues. These include training in epilepsy, diabetes and mental health as well as training in risk assessments and mental capacity. Forthcoming training includes risk assessments, makaton, safeguarding, supervision, record keeping, autism and dementia care. The service has also plans to have training for staff and the people that live there on equality and diversity issues from a specially trained po0lice officer. The service’s AQAA tells us that nearly 70 of staff are NVQ qualified. The examination of a sample of three staff files shows that the service is making the necessary pre employment checks. All files contained two references and satisfactory Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks. A staff member we spoke to said she had these checks before she started work. DS0000005110.V373682.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People living at the service benefit from a well run service that is run in their interests and promotes their welfare and safety. EVIDENCE: The service’s AQAA tells us that the people living at the service benefit from a consistent management team. The current Care Manager has worked at the service for a considerable time and has day-to-day contact with people living at the service. The manager is experienced and qualified. She undertakes regular training to keep her knowledge up to date. This year she has completed a ten-day leadership and management course. DS0000005110.V373682.R01.S.doc Version 5.2 Page 24 The service sent us with an AQAA when we asked for it. This gave us good information about what the service offers people living there, changes it had made and plans for the future. A system for reviewing and monitoring the service is in place and this includes getting the views of the people that live there. The service completes monthly audits to review the service people are receiving. This includes looking that people are receiving the health care they need, that support plans are up to date and risk assessments are in place. Other audits include looking at the environment. The service also regular asks people living there about their experiences through house meetings, individual meetings and through six monthly questionnaires. We saw evidence that the service acted upon comments made by the people that live there. The service’s AQAA confirms that the service completes checks of equipment such as the fire equipment, gas appliances and on the emergency call system. The fire officer had visited the service to check the fire safety prior to the registration of the additional accommodation in November 2008. People told us they had training in Health and Safety practices although some of the records needed updating. DS0000005110.V373682.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 3 ENVIRONMENT Standard No Score 24 4 25 X 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 4 34 3 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 4 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 4 X 3 X X 3 X DS0000005110.V373682.R01.S.doc Version 5.2 Page 26 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000005110.V373682.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000005110.V373682.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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